Why the War Over Health Care Isn’t Over

It’s worth dwelling on what we’ve learned as successive G.O.P. health-care bills have faltered. Some of the lessons are encouraging, and some aren’t.

Illustration by Joan Wong

The Trump era has conditioned us to brace for chaos, upheaval, and the
next story. On Tuesday, after Mitch McConnell, the Senate Majority
Leader, decided not to schedule a vote on a last-ditch Obamacare-repeal
bill put forward by Senators Lindsey Graham and Bill Cassidy, it took
only a few hours for the political world and much of the news media to
move on to the next item on the White House’s agenda: tax reform. But, before running forward into this new legislative battle, it’s worth
dwelling on what we’ve learned over the past few months, as successive
G.O.P. health-care bills have faltered. Some of the lessons are
encouraging, and some aren’t. Let’s start with the uplifting stuff.

Seven and a half years after Congress passed the Affordable Care Act,
the central value it enshrines—that affordable health care should be
available to everyone, regardless of age, income, or medical history—is
now widely accepted. Opinion polls show almost universal support for
this proposition. Donald Trump says he supports it, and so do Republican
leaders such as House Speaker Paul Ryan (although they tend to use
weasel words like “accessible” rather than “affordable”). That is why
the Republicans got into such political trouble when—after years of
promising to repeal Obamacare—they finally had to release details of
their plans for doing so. It turned out that their ideas would
lead to millions of poorer Americans losing coverage, while many seniors
and sick people would see their out-of-pocket costs soar. The Party’s
hypocrisy was exposed.

Another progressive idea included in the A.C.A. that has proven durable
is the notion that expanding health-care coverage is important enough to
justify higher taxes on the wealthy. When Donald Trump took office,
Republicans were determined to repeal two Obamacare tax increases that
had hit households earning more than a quarter of a million dollars a
year: a 0.9-per-cent surcharge on Medicare taxes and a 3.8-per-cent
investment tax. These increases had helped pay for the law’s insurance
subsidies and its big expansion of Medicaid. Yet going after these tax
increases left Republicans open to the accusation that their real
motivation was to help the Party’s wealthy donors. After McConnell’s
Better Care Reconciliation Act died, in mid-July, Republicans quietly
stopped pushing to get rid of these taxes. McConnell’s so-called “skinny
repeal,” which was voted down in the early hours of July 27th, and the
Graham-Cassidy bill both would have left these taxes in place. For a
Republican Party that views cutting taxes on the rich as one of its central
missions, that was a big retreat.

The general point is that the enactment of Obamacare, despite all the
criticisms it has received, has permanently shifted the political
debate. It is no longer enough for Republicans to argue that America
can’t afford a decent health-care system, or that the way to fix things
is to simply repeal the A.C.A. and leave the rest to the market. Having
seen the pluses and minuses of Obamacare, most Americans aren’t willing
to junk it in exchange for vague promises. Any potential replacement
must be able to withstand some detailed comparison shopping. Thus far,
no Republican plan has been able to meet that challenge.

The ubiquity of the Internet has played a role here. As the action on
Capitol Hill proceeded, practically everybody had access to the latest
health-care analyses from independent institutions like the
Congressional Budget Office, the Kaiser Family Foundation, and the
Commonwealth Fund. Most people didn’t actually read the studies these
organizations produced, of course. But the news media helped transmit
the key findings, and so did the round-the-clock social-media efforts of
experts including Kaiser’s Larry Levitt, the former Obama Administration
official Andy Slavitt, and the Center for American Progress’s Topher
Spiro. The C.B.O.’s studies, which showed that the G.O.P.’s plans would
lead to big drops in coverage and much higher premiums for people older than
fifty-five and those with preëxisting conditions, were arguably the
single biggest factor in public opinion turning against McConnell and
Ryan’s efforts. This month, when the Republicans tried to rush through
the Graham-Cassidy bill, they scheduled things so that the C.B.O.
wouldn’t have enough time to do a proper scoring. But this tactic
rebounded: it was widely, and rightly, seen as subterfuge.

For once, real news and real analysis won out over fake news, and
democratic activism defeated procedural stunts on Capitol Hill. On
Tuesday, I
noted that health-care-advocacy groups and Democratic activists had for months
pursued Senator Susan Collins, of Maine, putting pressure on her to vote
against her Party’s bills.

Of course, Collins might have decided to oppose the Republican repeal
bills even without the protests. (And, as I noted, the nation owes her its thanks.) But there can be no doubt that the activism had an
effect. Think back to what happened during April and May in the House of
Representatives, when Paul Ryan, trying to pass his American Health Care
Act, faced defections from moderate Republicans who represent places
such as New York, New Jersey, and Pennsylvania, and who were being
subjected to regular protests in their home districts. Ryan ultimately
got his plan through the House, but the wider repeal effort never really
recovered its momentum.

On the other side of the ledger, it must be acknowledged that, as the
Duke of Wellington is reputed to have said of the Battle of Waterloo, it
was a damn close-run thing. Had Collins, Lisa Murkowski, or John McCain
voted the other way on the “skinny repeal,” back in July,
the legislation would have proceeded to a House-Senate conference, where
it would probably have been broadened and passed. We don’t know for sure
how many Republicans would have supported the Graham-Cassidy bill if it
had come to an actual vote, but it surely would have been close, too.
Republicans have comprehensively lost the intellectual arguments: they
can’t cite a single reputable study showing that their bills would
preserve affordable coverage for the old, the sick, and the poor. But
that doesn’t appear to be enough to sway most G.O.P. senators. Either
because they feared primary challenges from the right or because they
had trotted out the anti-Obamacare patter for so long that they had come to
believe it, the vast majority of them toed the Party line. Especially
after Tuesday’s Senate primary result in Alabama—where the insurgent Roy Moore defeated the Party favorite Luther Strange—there is no reason to
expect this attitude to change. And there’s also no reason to believe
that the Republican Party won’t, at some point, launch yet another
repeal effort. In fact, it is only a question of when.

On Wednesday, Lindsey Graham, who had just watched his bill die, said
that the Party would return to health care immediately after passing tax
reform. But a legislative window for pushing through a health-care
measure with just fifty votes is closing, and, going forward, the
Republicans will need sixty votes to break a Democratic filibuster.
Unless, of course, they pass another budget-reconciliation bill, which
would give them another chance at a fifty-vote victory. Or they could
get rid of the filibuster altogether, a step which Donald Trump urged
them to do on Wednesday.

For now, it looks like the next repeal effort will have to wait until
after the 2018 midterms. But another thing we’ve learned in the past few
months is that you should never underestimate the determination of the
Republicans, and of their wealthy donors, to dismantle Obamacare, or their
eagerness to embrace practically any tactic that might help them achieve
their goal. “Bottom line is the ACA is not remotely safe between now &
2018 election,” Andy Slavitt tweeted on Wednesday. The forces of
enlightenment and progress have won another big battle. But the war
isn’t over.